Lecture PowerPoint to accompany

Foundations in
Microbiology
Sixth Edition

Talaro
Chapter 19
The Gram-Positive
Bacilli of Medical
Importance
Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
 Important Gram-Positive Bacilli

Three general groups:

1. Endospore-formers
Bacillus, Clostridium
2. Non-endospore-formers
Listeria, Erysipelothrix
3. Irregular shaped and staining properties
Corynebacterium, Proprionibacterium,
Mycobacterium, Actinomyces, Nocardia
2
4
 Spore-forming Bacilli
Genus Bacillus
Genus Clostridium

5
 The Genus Clostridium
• Gram-positive, spore-forming rods
• Anaerobic and catalase negative
• 120 species
• Oval or spherical spores produced only under
anaerobic conditions
• Cause wound infections, tissue infections, and
food intoxications

6
Clostridium:
• Not zoonosis : (animal human)
Gas gangraena : Cl. perfingens
Tetanus : Cl. tetanus
Botulism : Cl. botulinum

7
9
 Gas Gangrene
Clostridium perfringens
•most frequent clostridia involved in soft tissue
and wound infections - myonecrosis
•Spores found in soil, human skin, intestine,
animal and human but not zoonosis
•Predisposing factors – surgical incisions,
compound fractures, diabetic ulcers, septic
abortions, puncture wounds, gunshot wounds

10
 Virulence Factors
• Virulence factors
– toxins –
• alpha toxin – causes RBC rupture, edema
and tissue destruction
– collagenase
– hyaluronidase
– DNase

11
 Pathology
• Not highly invasive; requires damaged and
dead tissue and anaerobic conditions
• Conditions stimulate spore germination,
vegetative growth and release of exotoxins,
and other virulence factors.
• Fermentation of muscle carbohydrates
results in the formation of gas and further
destruction of tissue.

12
13
 Treatment and Prevention
• Immediate cleansing of dirty wounds, deep
wounds, decubitus ulcers, compound fractures,
and infected incisions
• Debridement of disease tissue
• Large doses of cephalosporin or penicillin
• Hyperbaric oxygen therapy
• No vaccines available

14
 Tetanus
• Clostridium tetani
• Common resident of soil and GI tracts of
animals especially in horse
• Causes tetanus or lockjaw, calf castration, a
neuromuscular disease,
• Human :Most commonly among veterinarian,
geriatric patients and IV drug abusers; neonates
in developing countries

16
 Pathology
• Spores usually enter through accidental puncture
wounds, burns, umbilical stumps, frostbite, and crushed
body parts.
• Anaerobic environment is ideal for vegetative cells to
grow and release toxin.
• Tetanospasmin – neurotoxin causes paralysis by
binding to motor nerve endings; blocking the release of
neurotransmitter for muscular contraction inhibition;
muscles contract uncontrollably
• Death most often due to paralysis of respiratory
muscles

18
 Treatment and Prevention
• Treatment aimed at deterring degree of
toxemia and infection and maintaining
homeostasis
• (ATS) inactivates circulating toxin but does not
counteract that which is already bound
• Control infection with penicillin or
tetracycline; and muscle relaxants
• Vaccine available; booster needed every 10
years
21
 Clostridial Food Poisoning
• Clostridium botulinum – rare but severe
intoxication usually from home canned food

22
23
 Botulinum Food Poisoning
• Botulism – intoxication associated with
inadequate food preservation
• Clostridium botulinum – spore-forming
anaerobe; commonly inhabits soil and water

25
 Clinical sign :
• Flaccid muscle paralysis and include progressive
motor paralysis, disturbed vision, difficulty in
chewing and swallowing, and generalized
progressive paresis. Death is usually due to
respiratory or cardiac paralysis. The toxin
prevents release of acetylcholine at motor
endplates (neuromuscular junction).
• In Reported clinical signs in horses are very
similar, with progressive muscle paresis,
recumbency, dysphagia, and decreased muscle
tone (tail, tongue, jaw), respiratory distress, and
26
 Pathogenesis
• Spores are present on food when gathered and
processed.
• If reliable temperature and pressure are not achieved air
will be evacuated but spores will remain.
• Anaerobic conditions favor spore germination and
vegetative growth.
• Potent toxin, botulin, is released.
• Toxin is carried to neuromuscular junctions and blocks
the release of acetylcholine, necessary for muscle
contraction to occur.
• Double or blurred vision, difficulty swallowing,
neuromuscular symptoms
28
 Botulism
• Poultry botulism – caused by ingested
spores that germinate and release toxin;
flaccid paralysis
• Pets : dogs, cats
• Farm : cattle (rare in Indonesia)

30
Clinical sign :

31
 Treatment and Prevention
• Determine presence of toxin in food,
intestinal contents or feces
• Administer antitoxin; cardiac and
respiratory support
• Infectious botulism treated with penicillin
• Practice proper methods of preserving and
handling canned foods; addition of
preservatives.

32
 Clostridial Gastroenteritis
• Clostrium perfringens
• Spores contaminate food that has not been
cooked thoroughly enough to destroy spores.
• Spores germinate and multiply (especially if
unrefrigerated).
• When consumed, toxin is produced in the
intestine; acts on epithelial cells, acute
abdominal pain, diarrhea, and nausea
• Rapid recovery
33
BATAS BAHAN KULIAH 19

34
 Gram-Positive Regular Non-Spore-
Forming Bacilli
Medically important:
• Listeria monocytogenes
• Erysipelothrix rhusiopathiae

35
 Listeria monocytogenes
• Non-spore-forming Gram-positive
• Ranging from coccobacilli to long filaments
• 1-4 flagella
• No capsules
• Resistant to cold, heat, salt, pH extremes and
bile
• Virulence attributed to ability to replicate in the
cytoplasm of cells after inducing phagocytosis;
avoids humoral immune system
36
37
 Epidemiology and Pathology
• Primary reservoir is soil and water; animal intestines
• Can contaminate foods and grow during refrigeration
• Listeriosis - most cases associated with dairy
products, poultry, and meat
• Often mild or subclinical in normal adults
• Immunocompromised patients, fetuses and neonates;
affects brain and meninges
– 20% death rate

38
 Diagnosis and Control
• Culture requires lengthy cold enrichment
process.
• Rapid diagnostic tests using ELISA available
• Ampicillin and trimethoprimsulfamethoxazole
• Prevention – pasteurization and cooking

39
 Erysipelothrix rhusiopathiae
• Gram-positive rod widely distributed in
animals and the environment
• Primary reservoir – tonsils of healthy pigs
• Enters through skin abrasion, multiples to
produce erysipeloid, dark red lesions
• Penicillin or erythromycin
• Vaccine for pigs

40
Gram-Positive Irregular Non-Spore-
Forming Bacilli

Medically important genera:

• Corynebacterium
• Proprionibacterium
• Mycobacterium
• Actinomyces
• Nocardia

41
• Pleomorphic; stain unevenly
• 20 genera; Corynebacterium, Mycobacterium,
and Nocardia greatest clinical significance
• All produce catalase, possess mycolic acids,
and a unique peptidoglycan.

42
 Corynbacterium diptheriae
• Gram-positive irregular bacilli
• Virulence factors assist in attachment and
growth.
– diphtherotoxin – exotoxin
• 2 part toxin – part B binds and induces endocytosis;
part A arrests protein synthesis

43
44
 Epidemiology and Pathology
• Reservoir of healthy carriers; potential for
diphtheria is always present
• Most cases occur in non-immunized children
living in crowded, unsanitary conditions.
• Acquired via respiratory droplets from carriers
or actively infected individuals

45
46
 Epidemiology and Pathology
2 stages of disease:
1. Local infection –upper respiratory tract
inflammation
– sore throat, nausea, vomiting, swollen lymph nodes;
pseudomembrane formation can cause asphyxiation
2. Diptherotoxin production and toxemia
– target organs primarily heart and nerves

47
 Diagnostic Methods
• Pseudomembrane and swelling indicative
• Stains
• Conditions, history
• Serological assay

48
 Treatment and Prevention
• Antitoxin
• Penicillin or erythromycin
• Prevented by toxoid vaccine series and
boosters

49
 Genus Proprionibacterium

• Propionibacterium acnes most common

• Gram-positive rods
• Aerotolerant or anaerobic
• Nontoxigenic
• Common resident of sebaceous glands
• Causes acne

50
 Mycobacteria: Acid-Fast Bacilli
• Mycobacterium tuberculosis
• M. leprae
• M. avium complex
• M. fortuitum
• M. marinum
• M. scrofulaceum
• M. paratuberculosis

51
 Genus Mycobacterium
• Gram-positive irregular bacilli
• Acid-fast staining
• Strict aerobes
• Produce catalase
• Possess mycolic acids and a unique type of
peptidoglycan
• Do not form capsules, flagella or spores
• Grow slowly
52
53
 Mycobacterium tuberculosis
• Tubercle bacillus
• Produces no exotoxins or enzymes that
contribute to infectiousness
• Virulence factors - contain complex waxes
and cord factor that prevent destruction by
lysosomes or macrophages

54
 Epidemiology of Tuberculosis
• Predisposing factors include: inadequate nutrition,
debilitation of the immune system, poor access to
medical care, lung damage, and genetics.
• Estimate 1/3rd of world population and 15 million
in U.S. carry tubercle bacillus; highest rate in U.S.
occurring in recent immigrants
• Bacillus very resistant; transmitted by airborne
respiratory droplets

55
 Course of Infection and Disease
• Only 5% infected people develop clinical
disease
• Untreated, the disease progresses slowly;
majority of TB cases contained in lungs
• Clinical tuberculosis divided into:
– primary tuberculosis
– secondary tuberculosis (reactivation or
reinfection)
– disseminated tuberculosis
56
 Primary TB
• Infectious dose 10 cells
• Phagocytosed by alveolar macrophages and
multiply intracellularly
• After 3-4 weeks immune system attacks,
forming tubercles, granulomas consisting of a
central core containing bacilli surrounded by
WBCs – tubercle
• If center of tubercle breaks down into necrotic
caseous lesions, they gradually heal by
calcification.
57
58
 Secondary TB
• If patient doesn’t recover from primary
tuberculosis, reactivation of bacilli can occur.
• Tubercles expand and drain into the bronchial
tubes and upper respiratory tract.
• Gradually the patient experiences more severe
symptoms.
– violent coughing, greenish or bloody sputum, fever,
anorexia, weight loss, fatigue
• Untreated, 60% mortality rate
59
 Extrapulmonary TB
• During secondary TB, bacilli disseminate to
regional lymph nodes, kidneys, long bones,
genital tract, brain, and meninges.
• These complications are grave.

60
 Diagnosis
1. In vivo or tuberculin testing
Mantoux test – local intradermal injection of
purified protein derivative (PPD); look for red
wheal to form in 48-72 hours- induration;
established guidelines to indicate interpretation of
result based on size of wheal and specific
population factors
2. X rays
3. Direct identification of acid-fast bacilli in
specimen
4. Cultural isolation and biochemical testing
61
62
 Management and Prevention of TB

• 6-24 months of at least 2 drugs from a list

of 11
• One pill regimen called Rifater (isoniazid,
rifampin, pyrazinamide)
• Vaccine based on attenuated bacilli Calmet-
Guerin strain of M. bovis used in other
countries

63
 Mycobacterium leprae: The Leprosy
Bacillus
• Hansen’s bacillus/Hansen’s Disease
• Strict parasite – has not been grown on artificial
media or tissue culture
• Slowest growing of all species
• Multiplies within host cells in large packets called
globi
• Causes leprosy, a chronic disease that begins in
the skin and mucous membranes and progresses
into nerves

64
 Epidemiology and Transmission of
Leprosy
• Endemic regions throughout the world
• Spread through direct inoculation from
leprotics
• Not highly virulent; appears that health and
living conditions influence susceptibility
and the course of the disease
• May be associated with specific genetic
marker

65
 Course of Infection and Disease
• Macrophages phagocytize the bacilli, but a
weakened macrophage or slow T cell response
may not kill bacillus.
• Incubation from 2-5 years; if untreated, bacilli
grow slowly in the skin macrophages and
Schwann cells of peripheral nerves
• 2 forms possible:
– tuberculoid – superficial infection without skin
disfigurement which damages nerves and causes loss of
pain perception
– lepromatous – a deeply nodular infection that causes
severe disfigurement of the face and extremities
66
 Diagnosing
• Combination of symptomology, microscopic
examination of lesions, and patient history
• Numbness in hands and feet, loss of heat and
cold sensitivity, muscle weakness, thickened
earlobes, chronic stuffy nose
• Detection of acid-fast bacilli in skin lesions,
nasal discharges, and tissue samples

67
 Treatment and Prevention
• Treatment by long-term combined therapy
• Prevention requires constant surveillance of
high risk populations.
• WHO sponsoring a trial vaccine

68
 Infections by Non-Tuberculosis
Mycobacteria (NTM)
• M. avium complex – third most common cause of
death in AIDS patients
• M. kansaii – pulmonary infections in adult white
males with emphysema or bronchitis
• M. marinum – water inhabitant; lesions develop after
scraping on swimming pool concrete
• M. scrofulaceum – infects cervical lymph nodes
• M. paratuberculosis – raw cow’s milk; recovered
from 65% of individuals diagnosed with Crohn’s
disease
69
 Actinomycetes: Filamentous Bacilli

• Genera Actinomyces & Nocardia are nonmotile

filamentous bacteria related to mycobacteria.
• May cause chronic infection of skin and soft
tissues
• Actinomyces israelii – responsible for diseases of
the oral cavity, thoracic or intestines -
actinomycoses
• Nocardia brasiliensis causes pulmonary disease
similar to TB.

70